Mental health agencies face budget pressure to work together more efficiently

After emerging from a private meeting with about two dozen behavioral health care authorities around the region, the city's top physician said Tuesday that the disparate system has little choice but to improve communication and efficiencies in response to announced cuts in inpatient and emergency services now provided by Louisiana State University's New Orleans hospital. "There is plenty we can do," New Orleans Health Commissioner Dr. Karen DeSalvo said.

Ellis Lucia, The Times-Picayune archiveDr. Karen DeSalvo

But she conceded that whatever improvements are made among a web of service providers -- public and private hospitals, specialty inpatient facilities, the state-run Metropolitan Human Services District, independent chemical detox facilities, community-based case management teams for patients with psychotic disorders, law enforcement agencies and the judicial system, temporary housing programs -- it almost certainly will have to be done with less money.

"Government is going to get smaller," DeSalvo said. "We don't want to do less. ... But these cuts will have in impact."

The LSU System Board of Supervisors on Friday announced a slate of cuts that will be fully implemented by March 5. The closures at Interim LSU Public Hospital and the DePaul mental health campus include about 10 percent of emergency room general beds and inpatient/surgical beds; half of the emergency mental health beds; nine out of 38 mental health inpatient beds; and all chemical detox beds. The state Civil Service Commission is expected next month to approve hundreds of layoffs in New Orleans and at other LSU medical centers.

The key to a response, DeSalvo said, is for disparate providers to do a better job coordinating what they do so that the patients most at-risk don't fall through the cracks. In cases involving only physical health, DeSalvo said the most at-risk, poorly managed patients have bad health outcomes and strain the public purse. Yet similar patients in the behavioral health system, she said, end up like John Reynolds, a 22-year-old schizophrenic who fatally shot his niece and nephew last March before killing himself.

"That's why this matters so much," DeSalvo said.

Using federal support, DeSalvo has for months has been leading strategy sessions involving multiple behavioral health providers that often refer to themselves as "the continuum of care."

Calvin Johnson, a retired judge who runs the Metropolitan Human Services District, for several years has worked to rebuild the multiparish agency charged with providing case management, crisis services, medicine and other outpatient services to poor and uninsured residents with mental health conditions or chemical addictions.

The state Department of Health and Hospitals, meanwhile, last year hired the private Magellan Health Care Services to run a statewide managed-care plan encompassing Medicaid's behavioral health services. Magellan hired Dr. Craig Coenson, previously Johnson's medical director, to run the system slated to launch in March.

Given all that action, the Tuesday meeting at City Hall wasn't the first time DeSalvo and other players have put their heads together and pledged improvements. LSU physicians and Metropolitan authorities have over the past few years integrated more of their operations, making it a matter of routine for mental health patients who are discharged from inpatient care to have at least a 30-day supply of medicine and be plugged into outpatient case-management services.

Still, the pressure for an even more integrated system garnered increased urgency with the LSU cuts. And, previous sessions notwithstanding, DeSalvo said "today was the first time some of these people have been at the same table with each other."

The historical problem, according to LSU's Dr. Roxane Townsend, interim CEO of the university's New Orleans hospital, is "nobody owns the system. Metropolitan has always been charged with outpatient services. We at LSU have been charged with inpatient services."

Townsend said she is encouraged with Metropolitans plans -- launched before LSU's budget cuts -- to increase its transitional housing capacity and reduce the average lengths of occupancy, key steps in reducing the demand for inpatient beds and alleviating backlogs in the Interim LSU Public Hospital emergency room. But she and DeSalvo agreed that achieving those goals won't necessarily offset the loss of nine DePaul beds.

DeSalvo rejected the notion that the previous integration of LSU services -- the work Johnson, Coenson and LSU physicians already have achieved -- has yielded the maximum results, measured either by patient outcomes or financial efficiency. She recalled her previous work at Charity Hospital.

"We had a year when 240 patients had 10 emergency room visits or more," she said. "Using the simplest math, that's at least $7 million to take care of 240 people.

"We know we have people like that" in the mental health system, she said. "We just don't have good enough data yet. But we went around the room today, and some of our folks, at LSU, at DePaul, at Metropolitan, they can look at their lists of patients and know who we should be worried about. We have to get to those people."